A Clinical Approach to Integrative Care for OUD Treatment Strategies

Understand the importance of a clinical approach to integrative care for OUD in promoting patients’ overall health and well-being.

Abstract

Hello, I’m Dr. Alex Jimenez, and I am deeply committed to providing comprehensive, evidence-based care through my work in chiropractic, as an Advanced Practice Registered Nurse (APRN), and as a Board-Certified Family Nurse Practitioner (FNP-BC), along with my certifications in functional medicine (CFMP, IFMCP), advanced traumatology (ATN), and chiropractic cranial and spinal trauma (CCST). In this educational post, I want to take you on a journey into the complex world of opioid use disorder (OUD). We will explore the historical roots of opioid use, from ancient medicinal practices to the development of powerful synthetic drugs that have fueled the modern crisis. We’ll delve into the science behind how these substances affect the brain and body, examining their relative potencies and the mechanisms of addiction. A significant portion of our discussion will be dedicated to dismantling the pervasive myths and stigma surrounding OUD, which create profound barriers to effective care. We will then transition to a comprehensive overview of evidence-based treatment strategies, including the crucial role of pharmacological interventions like buprenorphine, methadone, and naltrexone. We’ll also highlight the power of non-pharmacological approaches such as motivational interviewing and various behavioral therapies. Finally, I will explain how our multidisciplinary practice, Injury Medical Clinic PA, integrates chiropractic care, functional medicine, and conventional medical oversight to provide a holistic, patient-centered approach to recovery and overall wellness. This post is designed to be an easy-to-understand yet thorough resource, grounded in the latest research from leading experts in the field.

Our Integrative Approach to Health and Wellness

At Injury Medical Clinic PA, located in the heart of El Paso, Texas, we have cultivated a unique, multidisciplinary environment dedicated to holistic patient care. As a Doctor of Chiropractic and Family Nurse Practitioner, I bridge the gap between different healing disciplines. This collaborative model is anchored by the invaluable expertise of our Medical Director and Collaborative Physician, Dr. Maria Guadalupe Cardenas, MD. Dr. Cardenas is Board Certified in Internal Medicine (NPI #1164426749, Texas MD License #J2933) and brings over 40 years of profound experience as an internist to our team.

This MD-DC collaboration is the cornerstone of our practice. It ensures that every patient benefits from a comprehensive diagnostic process and a well-rounded treatment plan that incorporates the best of both medical and chiropractic worlds. Dr. Cardenas provides essential medical oversight, managing complex health conditions, prescribing necessary medications, and ensuring that our protocols meet the highest standards of medical safety and efficacy. My expertise in chiropractic care, functional medicine, rehabilitation, and personal injury allows me to focus on the biomechanical, neurological, and metabolic aspects of health. Together, we integrate these services to address not just the symptoms but the root causes of a patient’s condition, whether it’s chronic pain, an acute injury, or a complex disorder like OUD. This integrated approach allows us to offer services ranging from spinal adjustments and physical rehabilitation to functional nutrition and medical management, all under one roof, providing a seamless and supportive journey for our patients toward optimal health.

The Long and Complex History of Opioids

To truly understand the current opioid crisis, we must first travel back in time. The story of opioids is not a recent one; it is a long, winding road that stretches back millennia. It’s a history intertwined with medicine, culture, commerce, and unfortunately, human suffering. By understanding this journey, we can better appreciate the substances we deal with today and the societal context in which the current crisis emerged.

From Ancient Poppies to Modern Synthetics

The journey begins with the opium poppy, Papaver somniferum. Archaeological evidence shows that as far back as 3400 BC, people cultivated this plant in Mesopotamia. The ancient Sumerians called it Hul Gil, the “joy plant,” recognizing its euphoric and sedative properties. This knowledge was not lost; it was passed down through civilizations. By the 1400s, the Greeks and Romans were widely using opium as a powerful pain reliever. The famous Greek physician Hippocrates acknowledged its therapeutic utility, and later, the Roman physician Galen prescribed it for a host of ailments.

Moving forward to the 1500s, the Swiss-German physician Paracelsus famously created laudanum, an alcoholic tincture of opium, which he praised as a “stone of immortality.” During this period, opium was a key ingredient in many patent medicines, used not just for pain but also to treat conditions like diarrhea and coughs. It was a staple of the medical pharmacopeia.

The modern era of opioids began in the 19th century with a series of scientific breakthroughs that isolated and refined the active compounds within opium.

• 1803: Morphine is Extracted: A young German pharmacist named Friedrich Sertürner successfully isolated the primary active alkaloid from opium. He named it “morphium” after Morpheus, the Greek god of dreams, a fitting name for its potent sedative effects. Morphine was a revolutionary discovery, offering a standardized, quantifiable dose for pain relief that was far more reliable than raw opium.
• 1832: Codeine is Isolated: French chemist Pierre-Jean Robiquet isolated another opium alkaloid, codeine. It was found to be less potent than morphine and proved to be an effective cough suppressant, a use that continues to this day.
• 1874: Heroin is Synthesized: In a London laboratory, chemist C.R. Alder Wright first synthesized diacetylmorphine by boiling morphine with acetic anhydride. He didn’t pursue its commercial use. However, in 1897, the German pharmaceutical company Bayer began marketing it under the trade name “heroin,” promoting it as a non-addictive morphine substitute and cough suppressant. This, as we now know, was a catastrophic miscalculation.
• 1939: Methadone is Synthesized: During World War II, German chemists developed a fully synthetic opioid called methadone. They were seeking a pain reliever that did not rely on the opium poppy, as supply lines were disrupted. Methadone would later find a crucial role in the treatment of opioid addiction.
• 1959: Fentanyl is Developed: Belgian chemist Dr. Paul Janssen synthesized fentanyl. This marked a significant leap in potency. Fentanyl was developed for medical use as a powerful anesthetic and analgesic for severe pain, particularly in surgical settings. Its potency is staggering—approximately 50 to 100 times more potent than morphine.
• 1966: Buprenorphine is Discovered: Researchers in the United Kingdom synthesized buprenorphine, a semi-synthetic opioid. Its unique properties as a partial agonist would later make it a cornerstone of modern OUD treatment, offering a safer alternative to full agonists.

This timeline reveals a critical pattern: much of the recent history, and the development of the most potent and widely used substances today, has occurred within the last 200 years. Each discovery was initially hailed as a medical advancement, a new tool to conquer pain. Yet, with each step, the potential for misuse, dependence, and harm grew exponentially.

Understanding Opioid Potency: Morphine Milligram Equivalents (MME)

When we discuss different opioids, especially those we prescribe, it’s not enough to know their names. We must understand their relative strengths. The standard measure for this is the Morphine Milligram Equivalent (MME). This system allows us to compare the potency of various opioids to a baseline of 1 milligram of morphine, helping clinicians assess overdose risk when prescribing or converting a patient from one medication to another.

Let’s look at a list of common opioids, ordered by increasing potency, to understand what these MME values truly mean:

• Tramadol: This is often considered a “weaker” opioid, but it is still a potent medication. Its MME is 1. This means 10 milligrams of tramadol are roughly equivalent to 1 milligram of morphine.
• Codeine: Slightly more potent than tramadol, with an MME of 15.
• Hydrocodone: This is a very common prescription opioid, often found in combination products like Vicodin or Norco. Its potency is on par with morphine, with an MME of 1. So, 10 milligrams of hydrocodone is equivalent to 10 milligrams of morphine.
• Oxycodone: Found in medications like Percocet and OxyContin, this is more potent than morphine. Its MME is 5. This means 10 milligrams of oxycodone has the analgesic effect of about 15 milligrams of morphine.
• Hydromorphone (Dilaudid): This is a significantly more potent opioid, with an MME of 4. Just 1 milligram of hydromorphone is equivalent to 4 milligrams of morphine.
• Fentanyl (Transdermal Patch): Here, the numbers become truly alarming. Fentanyl’s potency is so high that it’s often measured in micrograms (mcg), not milligrams (mg). Its MME is often cited as 4 micrograms per 1 morphine milligram equivalent. This extreme potency is why illicitly manufactured fentanyl has become the primary driver of overdose deaths. A minuscule amount, invisible to the naked eye, can be a lethal dose.

Understanding MME is not just an academic exercise. It is a critical tool for safe prescribing. High daily MME dosages are directly linked to an increased risk of overdose and death. As clinicians, we must be constantly aware of the total MME a patient is receiving, especially if they are on multiple opioid medications.

The Three Waves of the U.S. Opioid Crisis

The declaration of the opioid crisis as a public health emergency in 2017 did not happen overnight. It was the culmination of a disaster that unfolded in three distinct and devastating waves, each driven by different substances and market forces. The Centers for Disease Control and Prevention (CDC) has meticulously tracked this epidemic, and their data paints a stark picture of its evolution.

Wave 1: The Rise of Prescription Opioids (1999–2010)

The first wave began in the late 1990s. During this time, the medical community underwent a major cultural shift in pain management. Pain was promoted as the “fifth vital sign,” and healthcare providers were encouraged to treat it more aggressively. Pharmaceutical companies aggressively marketed new formulations of prescription opioids, like OxyContin, claiming they were safe and had a low risk of addiction.

The results were catastrophic. From 1999 to 2010, the sales of prescription opioids in the United States quadrupled. As the volume of pills flooding communities increased, so did harm. Opioid-involved overdose deaths doubled during this period, rising from 2.9 to 6.8 deaths per 100,000 people. Many individuals who became addicted during this wave were first introduced to opioids through a legitimate prescription for acute or chronic pain.

Wave 2: The Resurgence of Heroin (2010–2013)

As the first wave crested, a crackdown on prescription opioid “pill mills” and new prescribing guidelines made it harder and more expensive to obtain prescription pills on the illicit market. For individuals who had developed a dependence, this created a desperate situation. The market responded. Heroin, which is chemically similar to prescription opioids but often cheaper and more readily available, saw a massive resurgence.

From 2010 to 2013, overdose deaths involving heroin surged dramatically, increasing from 1.0 to 4.9 per 100,000 people. During this period, for the first time in years, heroin deaths surpassed prescription opioid deaths. This wave highlighted a tragic and predictable transition: as one supply was restricted, a dependent population shifted to a more dangerous, unregulated alternative.

Wave 3: The Domination of Synthetic Opioids (2013–Present)

The third and most lethal wave began around 2013 with the infiltration of the illicit drug supply by powerful synthetic opioids, primarily illicitly manufactured fentanyl. As we discussed, fentanyl is incredibly potent. Drug traffickers began mixing it into heroin, pressing it into counterfeit pills made to look like oxycodone or other prescription drugs, and even mixing it with non-opioid substances like cocaine and methamphetamine.

The impact has been breathtakingly tragic. From 2013 to 2018, the death rate from synthetic opioids increased by over 1,000%, soaring from 1.0 to 11.4 deaths per 100,000 people. This is the wave we are still grappling with today. A terrifying new development within this wave is the emergence of non-opioid sedatives like xylazine (an animal tranquilizer) being mixed with fentanyl. This combination, known as “tranq,” increases the risk of overdose and causes severe, necrotic skin wounds, complicating treatment and harm reduction efforts. Up to 10% of fentanyl-related overdoses now involve xylazine.

This CDC graph visually demonstrates the shocking scale of these three waves. The teal line, representing commonly prescribed opioids, shows the first wave’s rise and subsequent leveling off. The orange line shows the second wave’s sharp increase in heroin deaths starting in 2010. But it is the purple line, representing synthetic opioids, that is most striking. It remains relatively flat until 2013, when it begins an almost vertical, exponential increase that dwarfs the death tolls of the previous two waves. The sheer magnitude of this third wave underscores the urgency of our current public health crisis.

The Scope of Opioid Misuse Today

To understand the scale of the problem we face, we can look at data from the 2021 National Survey on Drug Use and Health (SAMHSA). The numbers are sobering.

• In 2021, an estimated 2 million people aged 12 or older in the United States had misused opioids in the past year.

When we break this down, we see two main categories of misuse:

• Pain Reliever Misuse: This is the larger circle. Approximately 1 million people reported misusing prescription pain relievers only. This shows that despite the focus on illicit drugs, the misuse of prescribed medications remains a massive problem. We, as healthcare providers, must stay highly aware of this when prescribing.
• Heroin Use: The smaller circle represents about 5 million people who used only heroin.
• Overlap: A significant group of about 5 million people misused both prescription pain relievers and heroin.

In total, about 1.1 million people reported using heroin in the past year. While the number of people misusing prescription pain relievers is far greater, the higher potency and unregulated nature of heroin (and its frequent contamination with fentanyl) make it a major driver of overdose. These statistics highlight the need for comprehensive screening and an understanding of the true prevalence of misuse for each type of substance.

Key Legislation and Treatment Milestones

The legal and regulatory landscape surrounding opioids has evolved dramatically over the last century, reflecting society’s shifting understanding of these substances from medical tools to public menaces and, finally, to components of a treatable medical condition.

• 1914: The Harrison Narcotics Tax Act: This was one of the first major pieces of federal legislation to regulate opioids. It criminalized the non-medical use of opiates and required physicians, pharmacists, and manufacturers to register and pay a tax. This act effectively drove opioid use underground and marked the beginning of a punitive, rather than public health-based, approach.
• 1970: The Controlled Substances Act: This landmark law created the drug scheduling system (Schedules I through V) that we still use today. It also established the Drug Enforcement Administration (DEA) to regulate the manufacturing and distribution of controlled substances, including opioids.
• 1974: The Narcotic Addiction Treatment Act: This act recognized the unique role of methadone in treating opioid addiction. It stipulated that methadone for addiction treatment could only be dispensed through federally regulated opioid treatment programs (OTPs), also known as methadone clinics.
• 2000: The Drug Addiction Treatment Act (DATA 2000): This was a revolutionary piece of legislation. It created the “buprenorphine waiver,” or “X-waiver.” For the first time, it allowed qualified physicians to prescribe a Schedule III opioid (buprenorphine) for the treatment of OUD in an office-based setting, outside the confines of a traditional methadone clinic. This dramatically increased access to treatment.
• 2016: The Comprehensive Addiction and Recovery Act (CARA): Recognizing the need for more providers, CARA expanded the prescribing authority for buprenorphine to Nurse Practitioners (NPs) and Physician Assistants (PAs), further broadening the base of clinicians who could offer this life-saving treatment.
• 2018: The SUPPORT for Patients and Communities Act: This act aimed to bolster the fight against the opioid crisis by expanding care within Medicare and Medicaid for OUD treatment, addressing some of the financial barriers to access.
• 2023: The Mainstreaming Addiction Treatment (MAT) Act: This was another game-changing development. The MAT Act eliminated the buprenorphine waiver (X-waiver). Now, any prescriber with a standard DEA license who is permitted to prescribe Schedule III medications under their state license can prescribe buprenorphine for OUD. This legislation was a monumental step toward “mainstreaming” addiction care, treating it like any other chronic medical condition.

The Rationale for Treatment: Overcoming Myths and Stigma

The numbers tell a clear story: OUD is a widespread, deadly, and costly disease. In the United States, of the roughly 9 million adults who need treatment for OUD, only a little more than 2 million actually receive medications for opioid use disorder (MOUD). This staggering treatment gap is fueled by a combination of systemic barriers and deeply ingrained societal stigma. The economic impact is equally immense, estimated at over $193 billion annually in healthcare costs, lost productivity, and criminal justice expenses.

The demographic most likely to receive treatment is white males ages 35 to 49. This points to significant disparities in access and care for women, younger and older individuals, and racial and ethnic minorities. In 2022 alone, there were almost 82,000 opioid overdoses. This is not just a statistic; it is a public health catastrophe that demands an urgent, evidence-based response from every corner of our healthcare system.

Debunking Common Myths About OUD Treatment

To effectively treat OUD, we must first confront and dismantle the harmful myths that persist, even within the healthcare community. These myths create stigma, shame, and barriers to life-saving care.

• Myth 1: “Medications for opioid use disorder (MOUD) just replace one addiction with another.”

• • Truth: This is perhaps the most common and damaging myth. The best way to reframe this is to think about other chronic medical conditions. Would we ever say that giving insulin to a person with diabetes is “replacing one dependency with another”? Of course not. We are providing a medication that corrects a physiological imbalance and allows the person to function and live a healthy life. MOUD (like buprenorphine or methadone) works similarly. It stabilizes the brain’s opioid receptors, eliminating withdrawal and cravings, which allows the individual to engage in therapy, rebuild their life, and focus on recovery. It is a medical treatment for a medical disease.

• Myth 2: “Recovery without medication is ‘superior’ to recovery with medication.”

• • Truth: This creates a false hierarchy of recovery that is deeply stigmatizing. Let’s use another analogy: hypertension. We might recommend diet and exercise to a patient, and they might successfully lower their blood pressure. Another patient might follow the same recommendations but still need medication to achieve a healthy blood pressure. Would we consider the first patient’s treatment plan “superior” to the second? No. They are simply two different patients with two different physiological needs requiring two different treatment plans. The goal is a positive health outcome—a stable, healthy life—not adherence to a particular ideology of what “true” recovery looks like.

• Myth 3: “MOUD is not effective.”

• • Truth: This is demonstrably false. The scientific literature is overwhelmingly clear on this point. MOUD is the gold standard of care for OUD. Studies have consistently shown that being on MOUD reduces mortality by up to 60% or more. It dramatically reduces the risk of overdose, decreases illicit drug use, reduces the transmission of infectious diseases like HIV and Hepatitis C, and improves social functioning and retention in treatment.

• Myth 4: “MOUD is only for ‘weak’ people who can’t stop on their own.”

• • Truth: This statement is rooted in a fundamental misunderstanding of addiction as a moral failing rather than a complex brain disease. OUD is a chronic brain disorder that, in many ways, hijacks the brain’s reward, motivation, and decision-making circuits. The intense cravings and agonizing withdrawal are not a matter of willpower; they are powerful physiological and neurological phenomena. Treating this disease medically, with medications that correct the underlying neurobiology, is the most compassionate and effective approach, just as it is for any other chronic condition.

What Are Substance Use Disorders?

To move past the stigma, we must use precise, medical language. In the past, you may have heard terms like “abuse,” “dependence,” or “addiction.” The current clinical standard, as defined by the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), is Substance Use Disorder (SUD).

SUDs are defined as medical, chronic conditions that affect the brain’s structure and function. They are characterized by a pathological pattern of behaviors related to substance use. We categorize them by severity—mild, moderate, or severe—based on how many diagnostic criteria a person meets. The good news is that for OUD, and many other SUDs, there is effective, evidence-based treatment available.

The DSM-5 Criteria for Opioid Use Disorder

Understanding the specific diagnostic criteria from the DSM-5 is incredibly helpful because it shifts the focus away from specific quantities of a drug used and toward the impact on a person’s life and behavior. To be diagnosed with OUD, a person must meet at least two of the following 11 criteria within 12 months. The severity is graded as follows: 2-3 criteria = mild, 4-5 criteria = moderate, 6+ criteria = severe.

1. Using in larger amounts or for a longer period than intended. (e.g., “I only meant to take one pill, but I ended up taking four.”)
2. A persistent desire or unsuccessful efforts to cut down or control use. (e.g., “I’ve tried to quit so many times, but I just can’t.”)
3. Spending a great deal of time obtaining, using, or recovering from the effects of the substance. The substance becomes the central organizing principle of the person’s life.
4. Craving, or a strong desire or urge to use the opioid. This is an intense, intrusive thought that can be overwhelming.
5. Recurrent use failing to fulfill major role obligations at work, school, or home.
6. Continuing to use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the opioid. (e.g., arguments with family, losing friends).
7. Giving up or reducing important social, occupational, or recreational activities because of opioid use.
8. Recurrent use in situations in which it is physically hazardous. (e.g., driving while impaired, injecting in unsafe conditions).
9. Continued use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. This criterion highlights the “hijacking” of the brain’s decision-making system; the reward system overrides the logical understanding of harm.
10. Tolerance: This is defined by either (a) needing markedly increased amounts of the opioid to achieve the desired effect, or (b) a markedly diminished effect with continued use of the same amount.
11. Withdrawal: This is manifested by either (a) the characteristic opioid withdrawal syndrome (e.g., nausea, vomiting, muscle aches, anxiety) or (b) taking an opioid (or a closely related substance) to relieve or avoid withdrawal symptoms.

It’s critically important to note that criteria 10 (tolerance) and 11 (withdrawal) alone do not meet the criteria for OUD. A patient taking opioids as prescribed for chronic pain may develop both tolerance and physical dependence (and experience withdrawal if they stop abruptly). Still, if they are not exhibiting any of the other nine behavioral criteria, they do not have OUD. This distinction is crucial for accurate diagnosis and avoiding the mislabeling of chronic pain patients.

The Pervasive Impact of Stigma

Stigma is one of the most significant and insidious barriers to care for people with OUD. It operates on multiple levels—public, structural, and individual—and directly impacts health outcomes.

• Public Stigma: This manifests as the general public’s failure to recognize SUD as a chronic medical condition. When this happens, people with OUD are often viewed through a moral lens, leading to the belief that OUD is associated with criminality and personal weakness. This public sentiment translates into opposition to policies that increase treatment access, like the placement of treatment clinics or harm reduction services in a community (the “Not In My Backyard” or NIMBY phenomenon). Some studies have suggested that this stigma tends to increase with age.
• Structural Stigma: Stigma embedded within our institutions, laws, and policies.

• • Public Policy: A prime example is the “War on Drugs,” declared in 1971, which framed drug use as a crime rather than a health issue. This led to mass incarceration, disproportionately affecting racial and ethnic minorities, without providing adequate SUD treatment within the criminal justice system.
  • Healthcare System: The history of the X-waiver itself is a form of structural stigma. We required providers to undergo extra training and obtain a special license to prescribe buprenorphine, a treatment for OUD. At the same time, no such barrier existed for prescribing the very opioids that were causing the disorder.
  • Organizational Policies: Stigmatizing policies like mandatory drug testing for employment or housing can create insurmountable barriers for people in recovery, pushing them further to the margins of society. A lack of funding for treatment and prevention programs is another form of structural stigma.

• Individual and Internalized Stigma:

• • Individual Bias: This manifests in stereotypes (believing people with OUD are dangerous or unpredictable), prejudice (moral outrage, anger, and fear), and discrimination (providing coercive or substandard care, or refusing to treat patients with OUD). Provider bias is a major problem; studies show it can be higher in rural areas and among providers who view SUD as a moral failing. This bias directly reduces the likelihood of prescribing life-saving MOUD.
  • Internalized Shame: Perhaps most tragically, individuals with OUD often internalize this societal stigma. They may come to believe they are “less than” or morally flawed. This shame can prevent them from seeking help. They may also encounter communities (even some within the recovery world) that tell them they are not “truly sober” if they are on MOUD, which can lead them to discontinue effective medical treatment.

The Power of Language: Using Person-First Language

One of the most powerful tools we have to combat stigma is our language. Shifting to person-first language is a simple but profound way to reorient our thinking. It reminds us, and our patients, that we are treating a person with a disease, not a disease that defines a person.

Here are some practical examples of how to make this shift:

Avoid (Stigmatizing Language)	Use (Person-First Language)
Addict, junkie, user	Person with a substance use disorder, Person in recovery, Person who uses drugs (PWUD)
Abusing heroin	Misusing heroin, using heroin
Addicted baby	Baby born with neonatal opioid withdrawal syndrome (NOWS)
Clean / Dirty urine test	Negative/Positive test result; test result was negative for X/positive for Y.
Medication-Assisted Treatment (MAT)	Medications for Opioid Use Disorder (MOUD)
The shift from MAT to MOUD is particularly important. The old term, “medication-assisted treatment,” implies that medication is just an “add-on” or a crutch to the “real” treatment (therapy). The new term, MOUD, reflects reality: medication is treatment. It is a primary, evidence-based, life-saving intervention. Similarly, we are moving away from the word “abuse” and toward “misuse.” The word “abuse” carries heavy connotations of violence and judgment (e.g., physical abuse, emotional abuse). “Misuse” is a more neutral, objective term that describes using a substance in a way that is not prescribed or is harmful.

Putting It Into Practice: A Case Study in Language

Let’s review a sample case study, first with stigmatizing language, and then rewritten to demonstrate the power of a person-first approach.

Original (Stigmatizing) Version:

Substance use history: Patient reports abusing heroin IV from age 20 to 30. At age 20, she tried heroin with friends and began to use it daily soon after. Last use of heroin was one month ago after seven years clean. Substance use treatment history and behavioral health interventions: Entered recovery after an overdose. Started medication-assisted treatment. Patient strengths and protective factors: Has supportive family, regularly involved with addict community. History of non-fatal overdose three times; last overdose seven years ago prompted patient to enter rehab. Relevant family history: Father living, history of OUD in recovery for 30 years. Mother living, history of diabetes. No siblings. She has a female child, nine years old, born addicted to heroin, who is healthy now.

Now,let’ss identify the problematic words: “abusing,” “clean,” “medication-assisted treatment,” “addict community,” and “born addicted to heroin.” A baby cannot be “addicted” because addiction involves the behavioral components of the DSM-5 criteria. A baby can, however, be born with physical dependence and experience withdrawal.

Rewritten (Person-First) Version:

Substance use history: The patient reports misusing heroin IV from ages 20 to 30. She began to use it daily after age 20. Her last use of heroin was one month ago, after seven years of no use. Substance use treatment history and behavioral health interventions: She entered recovery after an overdose and started medications for opioid use disorder (MOUD). Her protective factors include a supportive family and regular involvement with the recovery community. History of non-fatal overdose three times; the last overdose seven years ago prompted the patient to enter a rehabilitation program. Relevant family history: Father is living, with a history of OUD, in recovery for 30 years. Mother living, with a history of diabetes. No siblings. She has a female child, nine years old, who was born with neonatal opioid withdrawal syndrome (NOWS) and is healthy now.

Notice how the second version reads differently. It is more respectful, more medically accurate, and less judgmental. This small change can have a massive impact on building trust and rapport with a patient.

Evidence-Based Treatments for Opioid Use Disorder

Effective treatment for OUD is multifaceted, combining pharmacological interventions, behavioral therapies, and harm reduction strategies. At the core of a successful therapeutic relationship is a patient-centered communication style known as motivational interviewing.

Motivational Interviewing: The Art of Collaborative Change

Motivational Interviewing (MI) is a counseling approach designed to help patients find their own internal motivation to change. It is not about confronting or persuading; it is a partnership. This approach is particularly effective for patients with OUD, who often feel judged and powerless.

The Spirit of MI: The philosophy of MI is built on four pillars:

1. Partnership: You are a collaborator, not an authority figure. You work with the patient, supporting their journey rather than dictating it.
2. Evocation: The motivation and solutions come from the patient, not from you. Your job is to “evoke” their own goals, values, and reasons for change.
3. Acceptance: This involves recognizing the patient’s absolute worth, respecting their autonomy (their right to make their own choices, even if you disagree), affirming their strengths, and demonstrating deep empathy.
4. Compassion: Your primary goal is to promote the patient’s welfare with a non-judgmental, non-blaming, and non-shaming attitude.

The Process of MI: The flow of a motivational interview generally follows four steps:

1. Engaging: Building that crucial therapeutic rapport and trust.
2. Focusing: Collaborating with the patient to identify a specific goal or target for change. What does the patient want to work on?
3. Evoking: The heart of MI. You elicit the patient’s “change talk”—their own arguments for change. What is their motivation?
4. Planning: Once the motivation is strong, you collaborate on a concrete plan. This involves identifying options, building support, and creating specific, achievable steps.

Practical MI Tools: OARS and DARN CATS

MI provides helpful acronyms that give structure to these conversations.

OARS: This framework helps guide your moment-to-moment interactions.

• O – Open-ended Questions: Invite the patient to tell their story. Instead of “Do you want to quit?” ask, “Can you tell me a little bit about your recovery journey?“
• A – Affirmations: Acknowledge the patient’s strengths and efforts. “That’s a really good idea of how you can avoid a situation where you might be tempted to use.“
• R – Reflective Listening: This is the most critical skill. Your goal is to reflect more than you question. Paraphrase and reflect what the patient says to show you are listening and to help them hear their own thoughts.
• S – Summaries: Periodically, pull together the key points of the conversation. “Let me make sure I understand. You’re saying that… Is that correct?“

DARN CATS: This acronym helps you listen for and elicit “change talk,” which predicts a commitment to change.

• D – Desire: “What do you hope our work will accomplish together?”
• A – Ability: “What do you think you might be able to change about your opioid use?”
• R – Reasons: “Why do you want to stop or cut back your use?” (This is where you find their core motivation—it might be to live for a child’s graduation, not just to “save their life.”)
• N – Need: “What needs to happen for you to feel ready to give up opioids?” (This helps identify barriers, like untreated depression or unstable housing).
• C – Commitment: “I want to…” (This is a statement of intent).
• A – Activation: “I am ready to reduce my use to two times a week.” (This shows a readiness to act).
• T – Taking Steps: “I’ve already started attending meetings.” (This reflects actions already taken).

The Stages of Change

When using MI, it’s crucial to listen for language that indicates where the patient is in their journey. The Stages of Change model helps us meet the patient where they are:

1. Pre-contemplation: The person is not considering change. (“I don’t think my drug use is impacting my life.”)
2. Contemplation: The person is ambivalent, weighing the pros and cons of change. (“I think my marriage will improve if I reduce my drug use.”)
3. Preparation: The person is planning to make a change soon. (“I have looked up an NA meeting to attend near my house.”)
4. Action: The person is actively making changes. (“I reduced the number of days per week I use drugs.” or “I’ve started on buprenorphine.”)
5. Maintenance: The person is working to sustain the change long-term. (“I have been using medications for opioid use disorder for a year now.”)

Our job is not to force someone from pre-contemplation to action in one visit. It’s to help them move one step forward, perhaps from pre-contemplation to contemplation.

Non-Pharmacological Management and Behavioral Therapies

Medication is a critical component of treatment, but it works best when combined with psychosocial support.

• Behavioral Therapy: This can be one-on-one counseling with a psychologist, social worker, or recovery coach. Peer-based support can also be an invaluable, low-cost option.
• Group Therapy: Mutual support groups offer a sense of community and shared experience that can be incredibly powerful for recovery.

• • SMART Recovery (Self-Management and Recovery Training): Based on principles of Cognitive Behavioral Therapy (CBT) and Rational Emotive Behavior Therapy (REBT).
  • 12-Step Programs (Alcoholics Anonymous, Narcotics Anonymous): A widely known spiritual (though not necessarily religious) framework centered on a “higher power.”
  • Secular Organizations for Sobriety (SOS): An alternative for individuals who prefer a non-religious, secular approach.

While these therapies are evidence-supported and highly beneficial, it is unethical and counterproductive to require participation as a condition of receiving MOUD. A patient’s access to life-saving medication should never be held hostage to meeting attendance. As a provider, I strongly encourage you to attend an open meeting of one of these groups. It will give you a deeper understanding of what you are recommending to your patients and the supportive environment available to them.

The Cornerstone of Care: Pharmacological Management (MOUD)

To understand how MOUD works, we must first understand how different substances interact with the opioid receptors in the brain, particularly the mu-opioid receptor. This receptor is responsible for both the pain-relieving effects of opioids and their dangerous side effects, like respiratory depression.

Opioid Receptor Binding Properties: A Spectrum of Action

There are three main types of interaction with the mu-receptor:

1. Full Agonists: These substances bind to and fully activate the mu-receptor. This produces the maximum possible opioid effect. As you increase the dose, the effect continues to increase, leading to a high risk of euphoria, sedation, and, most dangerously, respiratory depression. Examples include morphine, heroin, methadone, oxycodone, and fentanyl.
2. Partial Agonists: These substances bind to the mu-receptor but only partially activate it. The key example here is buprenorphine. It produces a weaker opioid effect than a full agonist. Crucially, it has a ceiling effect. This means that after a certain dose, increasing the dose further does not produce a greater effect. This ceiling is below the threshold for severe respiratory depression, making it a much safer option.
3. Antagonists: These substances bind to the mu-receptor but do not activate it. Instead, they block the receptor, preventing any agonist (full or partial) from binding and having an effect. Examples include naloxone and naltrexone.

This graph provides a simplified visual representation. On the x-axis is the dose, and on the y-axis is the opioid effect (including respiratory depression).

• The antagonist (naltrexone) line is flat along the bottom. No matter the dose, there is no opioid effect.
• The full-agonist line (in gray) shows that as the dose increases, the effect keeps going up, eventually crossing the black line that represents the threshold for life-threatening respiratory depression.
• The partial agonist line (buprenorphine) shows that the effect increases with the initial dose but then hits a plateau or “ceiling,” leveling out safely below the respiratory depression threshold.

FDA-Approved Medications for Opioid Use Disorder

The FDA approves three main medications for the treatment of OUD.

1. Methadone

• Mechanism: Methadone is a long-acting full agonist at the mu-opioid receptor.
• How it Works: By occupying and activating the opioid receptors, it prevents withdrawal symptoms and reduces cravings. Because it is a full agonist, its dosing must be carefully managed.
• Regulation: It is a Schedule II controlled substance. Due to its risk profile as a full agonist, federal law restricts its dispensing for OUD to certified Opioid Treatment Programs (OTPs), or methadone clinics.
• Side Effects: Standard opioid side effects like constipation, dizziness, sedation, nausea, and sweating.
• Serious Side Effects: The most significant concern is QTc prolongation, an electrical abnormality in the heart that can lead to fatal arrhythmias. This risk increases at doses over 100 mg per day and requires EKG monitoring. As a full agonist, it also carries a risk of respiratory depression, especially when combined with other sedatives.
• Contraindications: Allergy, acute or severe asthma (due to respiratory risk), and gastrointestinal obstruction (as it slows gut motility).

2. Buprenorphine

• Mechanism: Buprenorphine is a mu-receptor partial agonist and a kappa-receptor antagonist.
• How it Works: Its unique properties make it an incredibly effective and safe treatment.

• Strong Affinity: It has a very high affinity (or “stickiness”) for the mu-receptor, even stronger than full agonists like heroin or fentanyl. This means if a person uses another opioid while on buprenorphine, the buprenorphine will “win” the competition for the receptor, blocking the effects of the other opioid.
• Partial Agonism & Ceiling Effect: As a partial agonist, it provides enough opioid effect to eliminate withdrawal and cravings but not enough to produce a significant “high.” Its ceiling effect provides a built-in safety mechanism, dramatically reducing the risk of overdose.

• • Precipitated Withdrawal: Because of its high affinity, if buprenorphine is given to someone who has a full agonist (like heroin) fully activating their receptors, the buprenorphine will bind, kick the heroin off, and rapidly bring the level of receptor activation down from the full agonist level to its own partial agonist ceiling. This sudden drop causes a rapid and severe withdrawal syndrome known as precipitated withdrawal. This is why we must induce buprenorphine only when a patient is already in a state of moderate withdrawal. Their receptors are already “empty,” so the buprenorphine will bring them up to the ceiling, providing relief.
• Regulation: It is a Schedule III controlled substance. Thanks to the MAT Act of 2023, any provider with a DEA license can prescribe it for OUD.
• Side Effects: Common opioid side effects include headache, constipation, nausea, and orthostatic hypotension. Because many formulations are sublingual (dissolve under the tongue), oral hypoesthesia (numbness) can occur.
• Serious Side Effects: Respiratory depression is a risk but is much rarer than with full agonists and usually occurs only in combination with other sedatives like benzodiazepines or alcohol. Hepatotoxicity (liver damage) is a rare but possible side effect.
• Drug Interactions:

• • Benzodiazepines: The FDA has issued guidance stating that while the combination of buprenorphine and benzodiazepines increases the risk of respiratory depression, the benefit of treating OUD with buprenorphine almost always outweighs the risk. Withholding buprenorphine from a patient on a stable dose of benzodiazepines could lead them to use illicit fentanyl, which carries a much higher overdose risk. Careful monitoring is key.
  • CYP3A4 Inhibitors & Inducers: Be mindful of drugs that affect the metabolism of buprenorphine. Inhibitors (like erythromycin, some antifungals, grapefruit juice) will increase its concentration, while inducers (like rifampin, St. John’s Wort) will decrease its concentration.
  • Serotonergic Drugs: Buprenorphine has some serotonergic properties, so use caution when combining it with other serotonergic agents like SSRIs, though the risk of serotonin syndrome is low.

3. Naltrexone

• Mechanism: Naltrexone is a mu- and kappa-opioid receptor antagonist. It completely blocks the opioid pathway.
• How it Works: It reduces cravings and, by blocking the receptors, prevents a person from feeling any effect if they do use an opioid. This can extinguish the rewarding aspect of use. It is also used for Alcohol Use Disorder, where it works by reducing alcohol-induced dopamine release.
• Regulation and Formulations: It is not a controlled substance. It comes in two forms:

• • Oral (PO): A daily pill, typically 50 mg. The challenge here is daily adherence.
  • Injectable (Vivitrol): A long-acting injectable suspension (380 mg) given as a deep intramuscular gluteal injection once a month. This formulation overcomes the adherence issue.

• Important Consideration: Because it is a full antagonist, a patient must be completely free of all opioids for 7-10 days before starting naltrexone. If given sooner, it will precipitate a severe and prolonged withdrawal. This “washout” period can be a significant barrier for many patients.
• Side Effects: Headache, anorexia, diarrhea, nausea, and injection site reactions are common.
• Serious Side Effects: Acute hepatitis is a major concern, requiring liver enzyme monitoring. Depression and suicidal ideation have also been reported.
• Contraindications: Acute hepatitis, liver failure, and current opioid use. A patient on naltrexone must be counseled that they will have no response to opioid pain medication in an emergency (e.g., after a car accident) and should carry a wallet card or medical alert bracelet.

The Role of Naloxone

Naloxone (brand name Narcan) is an opioid antagonist that serves a different but equally vital purpose: overdose reversal.

• Mechanism: When a person is overdosing on a full agonist like fentanyl, their respiratory drive is suppressed. Naloxone has a very high affinity for the mu-opioid receptor. When administered, it rapidly binds to the receptors, bumping the fentanyl off and immediately reversing the respiratory depression.
• Shorter Half-Life: A critical point to understand is that naloxone has a shorter half-life than most opioids, especially long-acting ones like fentanyl. This means that after 30-90 minutes, the naloxone will wear off and unbind from the receptors. The fentanyl, which is still circulating in the person’s system, can then re-bind to the receptors and cause the overdose to resume. This is why it is essential to call 911 and seek emergency medical care even after naloxone has been successfully administered. The person needs to be monitored.
• Co-Prescribing: As providers, we should be co-prescribing naloxone to any patient who is on opioids for pain, any patient with a history of OUD, and frankly, any patient who reports using any illicit drugs. The drug supply is so contaminated with fentanyl that even people using what they believe to be cocaine or methamphetamine are at risk of an opioid overdose.
• Formulations: It is most commonly available as a 4 mg intranasal spray (Narcan). It is designed to be easy for laypeople to use. Each box usually contains two single-dose devices. The protocol is to administer one dose in one nostril, wait 2-3 minutes, and if the person has not responded, administer the second dose in the other nostril. Family and friends should be trained to use it.

Naloxone in Combination Products

You will often see buprenorphine prescribed in a combination product with naloxone (e.g., Suboxone). The purpose of naloxone in this formulation is to deter misuse.

• When the tablet or film is taken sublingually as directed, the buprenorphine is absorbed into the bloodstream, but the naloxone is not (it has very poor oral/sublingual bioavailability). It has no effect.
• However, if a person were to crush the tablet and attempt to inject it intravenously, the naloxone would be bioavailable. It would immediately block the opioid receptors, precipitating withdrawal and preventing any euphoric effect from the buprenorphine.

Harm Reduction: A Pragmatic and Compassionate Approach

Harm reduction is a set of practical strategies and ideas aimed at reducing the negative consequences associated with drug use. It is a movement that meets people where they are, accepting that, for many, immediate abstinence is not realistic or achievable. The focus is on keeping people alive and as healthy as possible.

• Naloxone Distribution: As discussed, this is the cornerstone of overdose prevention.
• Fentanyl Test Strips: These small paper strips allow a person to test their drug supply for the presence of fentanyl before they use it. This empowers them to make a more informed decision and can deter use or encourage safer use practices (e.g., using a smaller amount).
• Never Use Alone Hotline: This is a life-saving service where a person can call a confidential hotline before they use drugs. They provide their location, and an operator stays on the line. If the person becomes unresponsive, the operator immediately calls emergency services to that address.
• Clean Needle Exchanges (Syringe Service Programs): These programs provide sterile syringes and other injection equipment to people who inject drugs. This dramatically reduces the transmission of bloodborne pathogens like HIV and Hepatitis C, saving lives and massive healthcare costs.
• Urine Drug Screens (UDS): In a clinical setting, we can use UDS not as a punitive tool, but as a harm reduction tool. When a patient who reports only using heroin has a UDS that is positive for fentanyl, it opens the door for a non-judgmental conversation. “I see fentanyl in your results today. Were you aware of that? This is very common, as the supply is often contaminated. This puts you at a much higher risk of overdose. Let’s talk about how we can keep you safe.“
• Prescription Drug Monitoring Programs (PDMPs): These state-level electronic databases allow prescribers and pharmacists to see a patient’s prescription history for controlled substances. This helps us coordinate care, prevent dangerous drug interactions, and identify patients who may be struggling.
• Motivational Interviewing: As discussed, the very philosophy of MI—prioritizing the patient’s goals and collaborating with them—is a form of harm reduction. It respects their autonomy and focuses on any positive change, no matter how small.

Enhancing Health Together: Embracing Multidisciplinary Evaluation and Treatment- Video

How Integrative Chiropractic Care Fits into OUD Treatment

Now, you might be wondering, “Where does chiropractic care fit into this complex picture of OUD treatment?” This is where our unique, integrated model at Injury Medical Clinic, with the medical direction of Dr. Cardenas, becomes so powerful. Recovery from OUD is not just about stabilizing brain chemistry; it’s about healing the whole person—mind, body, and spirit. Many individuals with OUD have co-occurring chronic pain, musculoskeletal issues, and a profoundly dysregulated nervous system. This is where chiropractic and functional medicine can play a crucial supportive role.

• Managing Chronic Pain: The opioid crisis began, in large part, as a response to the undertreatment of pain. Many individuals who develop OUD initially received opioids for a legitimate pain condition. As a Doctor of Chiropractic, my primary expertise lies in the non-pharmacological management of neuromusculoskeletal pain. Through chiropractic adjustments, soft tissue mobilization, physical rehabilitation exercises, and postural correction, we can address the root biomechanical causes of pain in the spine, joints, and muscles. By providing effective, non-addictive pain relief, we can help reduce a patient’s perceived need or craving for opioids, supporting their long-term recovery. This is a vital alternative to simply prescribing more pills.
• Regulating the Autonomic Nervous System: Chronic substance use, trauma, and stress throw the autonomic nervous system (ANS) into a state of severe dysregulation. The ANS has two main branches: the “fight-or-flight” sympathetic system and the “rest-and-digest” parasympathetic system. In individuals with OUD, the sympathetic system is often in a state of chronic overdrive, leading to anxiety, agitation, insomnia, and heightened pain sensitivity. Chiropractic adjustments, particularly of the upper cervical spine, have been shown to have a powerful modulating effect on the ANS. By improving spinal mechanics and reducing nerve interference, adjustments can help down-regulate the sympathetic response and promote a shift toward a more balanced, parasympathetic state. This can help calm the nervous system, reduce anxiety, improve sleep, and create a greater sense of well-being, which is invaluable for a person in early recovery.
• Functional Medicine and Nutritional Support: As a Certified Functional Medicine Practitioner (CFMP, IFMCP), I look at the body as an interconnected system. Chronic opioid use depletes vital nutrients, disrupts the gut microbiome (leading to issues like constipation and “leaky gut”), and causes systemic inflammation. A functional medicine approach uses specialized testing to identify these imbalances and create a personalized plan to correct them. This might include:

• Targeted Nutritional Supplementation: Replenishing depleted nutrients like B vitamins, magnesium, and zinc, which are crucial for neurotransmitter production and neurological health.
• Anti-Inflammatory Diet: Guiding the patient toward a whole-foods-based diet rich in phytonutrients to reduce systemic inflammation.
• Gut Health Restoration: Using probiotics, prebiotics, and other interventions to heal the gut lining and restore a healthy microbiome, which is now understood to have a profound impact on mood and brain health (the “gut-brain axis”).

• • A Supportive and Healing Environment: Under the medical supervision of Dr. Cardenas, who manages the pharmacological aspects of care, including MOUD, and treats co-occurring medical conditions, our clinic provides a safe, non-judgmental space. When a patient comes to us, they are not just seeing a “chiropractor” or a “doctor.” They are entering a therapeutic environment where a team is dedicated to their holistic well-being. They receive hands-on care that is inherently therapeutic and builds trust. This comprehensive, integrative approach addresses the pain, the neurological dysregulation, and the biochemical imbalances that often underlie and perpetuate OUD, providing a powerful adjunct to standard medical and psychological treatment.

Conclusion

The history of opioids provides a crucial context for understanding the crisis we face today. From ancient remedies to modern synthetic marvels, our relationship with these powerful substances has always been complex. The journey through the three waves of the U.S. opioid crisis shows a clear and tragic progression, culminating in the current public health emergency driven by fentanyl.

As we move forward, our path must be guided by science and compassion, not by stigma and myth. Stigma remains one of the most significant barriers to treatment and has a direct, negative impact on patient outcomes. We must all commit to using person-first language and to viewing OUD as the chronic, treatable medical condition that it is.

Effective, evidence-based treatment for OUD is available and highly effective. This includes pharmacological interventions like buprenorphine, methadone, and naltrexone, which are the gold standard of care, as well as psychosocial therapies and pragmatic harm reduction techniques that keep people alive. In our practice, we have seen the profound benefits of integrating these medical treatments with holistic approaches like chiropractic care and functional medicine to address the physical pain, neurological dysregulation, and nutritional deficiencies that so often accompany OUD.

By embracing a comprehensive, compassionate, and evidence-based approach, we can begin to turn the tide on this devastating crisis and help individuals on their journey toward healing and recovery. Thank you for taking the time to join me on this educational journey. If you have any questions, please do not hesitate to reach out.

Clinical Observations of Dr. Alexander Jimenez:

My clinical experience, documented across platforms like PUSHASRx.com and my professional profile on LinkedIn, has consistently shown that patients with OUD and co-occurring chronic pain respond exceptionally well to an integrative care model. By combining MOUD, managed under the expert medical direction of Dr. Cardenas, with targeted chiropractic adjustments, we can often significantly reduce pain scores. This, in turn, lessens the patient’s psychological reliance on opioids for pain relief. Furthermore, I have observed marked improvements in anxiety levels, sleep quality, and overall mood in patients receiving regular chiropractic care, which I attribute to the regulatory effect of adjustments on the autonomic nervous system. This holistic approach not only supports their recovery from OUD but also empowers them with non-pharmacological tools to manage their health long-term.

References

• Barthwell, A. G., & Brown, J. D. (2023). The Mainstreaming Addiction Treatment Act: A historic and overdue change to the treatment of opioid use disorder. Journal of the American Pharmacists Association, 63(3), 743–746.
• Centers for Disease Control and Prevention. (2021). U.S. Opioid Dispensing Rate Maps. CDC.gov.
• Centers for Disease Control and Prevention. (2023). Understanding the Opioid Overdose Epidemic. CDC.gov.
• Kampman, K., & Jarvis, M. (2015). American Society of Addiction Medicine (ASAM) National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. Journal of Addiction Medicine, 9(5), 358–367.
• Kennedy-Hendricks, A., Busch, S. H., McGinty, E. E., Bachhuber, M. A., & Barry, C. L. (2016). Primary care physicians’ perspectives on prescribing opioids to patients with chronic noncancer pain. JAMA Internal Medicine, 176(7), 959-968.
• Krawczyk, N., Picher, C. E., & Saloner, B. (2022). The “X-Waiver” Is Gone: Now What? American Journal of Public Health, 113(3), 253–256.
• Ling, W., & Wesson, D. R. (2003). Clinical efficacy of buprenorphine: comparisons to methadone and placebo. Drug and Alcohol Dependence, 70(2 Suppl), S49-S57.
• Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). The Guilford Press.
• National Institute on Drug Abuse. (2023). Opioid Overdose Crisis. NIDA.
• Salsitz, E., & Winstanley, E. L. (2022). The past, present, and future of medications for opioid use disorder. Journal of Substance Abuse Treatment, 141, 108833.
• Substance Abuse and Mental Health Services Administration. (2022). Key substance use and mental health indicators in the United States: Results from the 2021 National Survey on Drug Use and Health. Center for Behavioral Health Statistics and Quality, SAMHSA.
• Volkow, N. D., & Blanco, C. (2020). The changing opioid crisis: development, challenges and opportunities. Molecular Psychiatry, 26, 218–233.
• Wakeman, S. E., & Barnett, M. L. (2018). Primary care and the opioid-overdose crisis—buprenorphine myths and realities. New England Journal of Medicine, 379(1), 1-4.

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